Is your skin developing any visible white patches?

Since when did you start noticing these marks?

Where do you generally find these patches?

Multiple selection

Does your skin experience any symptoms?

Multiple selection

Do you have any family history of vitiligo/ any other skin problem?

Do you suffer any of the below. Tick the relevant one

Multiple selection

Are you undergoing any treatment?

What does the medicine comprise of?
Tick wherever relevant.

Multiple selection

Is your skin problem affecting you emotionally?

On the scale of 1-5 rate your stress level